Before departure for any expedition or trip to a remote area, a medical plan should be written to assess for dangers and mitigate risk.

The template below can be used to support your pre-deployment medical plan.

Need support with your event or writing your plan? Email tom@guidebase to see how we can help. 

This medical plan outlines a summit attempt on Mount Elbrus, Russia. It should be adapted to meet your team and expedition. 

 

Contents

 

List of Tables. 1

Introduction. 2

Briefing. 3

Environment 3

Population. 3

Activities. 4

Primary Medical Care. 4

Secondary Medical Care. 5

Risk Assessment 5

Specific Risks. 7

Primary Hypothermia. 7

Rationale. 7

Risk Assessment 7

Risk Management 8

Treatment and Management 9

Limitations of Treatment and Management 12

Control Measures and Plan. 12

High Altitude-Related Illness. 13

Rationale. 13

Risk Assessment 13

Risk Management 15

Treatment and Management 16

Limitations of Treatment and Management 17

Control Measures and Plan. 17

Conclusion. 18

Reference List 24

 

List of Tables and Appendices

Table 1: The Swiss Staging System for Hypothermia (Strapazzon et al., 2014) 11

Table 2: Lake Louise Score (Roach et al., 2018) 16

Appendix A: Risk Assessment for Ascending Mount Elbrus. 19

 


 

Introduction

In October 2021, four British paramedics and two Russian mountain guides will attempt the summit of Mount Elbrus, Russia via the north route. Mt Elbrus is the highest mountain in Europe, standing at 5642m (meters above sea level) in the western aspect of the Caucasus Mountain range.

The north route to the summit will be attempted over 10 days, involving 45 kilometres of hiking and nearly 6000m of vertical ascent. All food and equipment will be carried by the individual team members, without the assistance of porters or snowmobiles.

Due to the environmental dangers and ever-changing hazards of Mount Elbrus, team members must have a competent knowledge of risk management for the specific mountain environment. However, permanent infrastructure on Mt Elbrus is limited and access to specialist personnel such as medical staff is challenging; thus, ingenious and situation-specific solutions may be required when devising a pre-deployment medical plan.

This medical plan identifies and assesses the risks presented by ascending Mt Elbrus. While lesser risks are considered, prominent dangers are comprehensively explored. 

 


 

Briefing

Environment

Mt Elbrus is one of the ‘seven summits’ and is situated in the southern Russian republic of Kabardino-Balkaria. It has an eastern and western peak, both of which are dormant volcanos. The Caucasus range surrounding Mt Elbrus is mountainous with 32 peaks exceeding 4000m.

In summer, the temperatures at the Mt Elbrus summit can reach 10° centigrade thanks to its location in the northern hemisphere, although this regularly drops to -50° centigrade during winter. Notably, it is the wind and changeability of weather that makes Mt Elbrus a dangerous mountain; while above 4000m it is not uncommon for arctic blizzard conditions to occur with winds to exceeding 100 km/h.

The mountain’s north route has a success rate of approximately 30%, compared to 80% via the south route. This is partly due to the north side’s lack of permanent infrastructure. At base camp (2600m), there are stationary huts and tents providing shelter, electricity, and hot water. Summit camp (3800m) is the last permanent building providing shelter and electricity (via a generator) before the summit. There is also an emergency shelter at 5416m that can accommodate four to five people.

Population

Mt Elbrus is a popular mountain, not only due to its status as one of the seven summits, but also because it is technically easy compared to similar high-altitude climbs. However, 15 to 30 people die annually attempting to summit, and political unrest among Chechen extremists remains a constant threat.

The population of this team include five adult males aged between 25 and 30, all of whom have completed a pre-screening medical questionnaire prior to traveling from England to Russia. The team has varying degrees of experience in high-altitude mountaineering, ranging from guided expeditions to 4000m in the French Alps to previous summits on Mt Elbrus itself.

Team members traveling into Russia from other countries will be required to present a negative COVID-19 test and be asymptomatic prior to entering the country.

Activities

Mountaineering on Mt Elbrus consists mainly of walking in crampons, setting and clipping into fixed lines, navigation, crevasse avoidance, erecting tents and the preparation of food and water.

Communication with rescue services and weather forecasting is conducted via radio and mobile telephone services.

Primary Medical Care

Medical cover is provided by team members who are either paramedics or mountain guides with advanced first aid training. All members have comprehensive knowledge of the medical equipment that will be carried by the team.

There are two rescue posts. The first is at Terskol and the second at Shkhelda Alpine Camp, both are located on the south side of Elbrus. Access is either by foot, helicopter, or snowcat. Time to each rescue post is two to twelve hours from the north face of the mountain, depending on location and weather.

Further medical support is rendered by helicopter medical rescue based at the foot of the south side of Mt Elbrus.

Secondary Medical Care

The nearest hospital facility to the north side of Elbrus is the City Clinical Hospital, Pyatigorsk. Evacuation to this facility would involve team-assisted rescue to base camp, then an all-terrain vehicle from base camp back across the river and along the off-road tracks to the road and then to the city, representing a total journey time of approximately five hours from base camp.

The City Clinical Hospital is a private hospital specialising in vascular surgery that provides all major medical and surgical specialities, with both MRI and CT imaging available.

 

Risk Assessment

To suitably assess, evaluate and manage the risks involved in high-altitude mountaineering, this medical plan employs a qualitative model of risk assessment (National Patient Safety Agency, 2007). To determine prioritisation of risk management, risk is broken down and defined by the ‘hazard’, a quantitative explanation of the cause of harm, and ‘severity’, the quantitative likelihood of the hazard occurring, along with an assessment of the damage it may cause (National Patient Safety Agency, 2007).

The Health and Safety Executive (HSE) (2006) describes the five steps involved in undertaking a risk assessment:

1. Hazard identification

2. Individuals at risk, including mechanism of risk occurrence

3. Risk assessment and prevention methods

4. Evaluation of findings and implementation strategy

5. Continuous adaption based on changes in environment, situation and person

Appendix A presents a qualitative risk assessment for ascending Mt Elbrus via the north route using the HSE (2006) model.

When undertaking a risk ‘severity’ assessment, the Health and Safety Executive (HSE) (2006) recommend the following four steps.

Avoidance aims to reduce the probability of harm occurring to zero, or as close to zero as is feasibly possible. It is of note that mountaineering presents innate risks, many of which cannot be avoided; thus, avoidance may often be impractical.

Mitigation prioritises a reduction in the severity of a risk. For example, increasing pace to reduce time under a serac is a method of mitigating ice fall injury.

Transference is a method of distributing risk among several parties. For example, in mountaineering, having multiple radios distributed among team members addresses the risk of critical equipment failure or loss.

Acceptance of risk relates to a situation in which risk cannot be completely avoided or mitigated; accordingly, one accepts that the risk of harm is both inevitable and outweighed by the potential benefit. An example of this is unforeseen poor weather adversely affecting individuals ascending a mountain when descent to safety is impeded.

 

Specific Risks

Primary Hypothermia

Rationale

Primary hypothermia can be defined as a core body temperature of <35°C where environmental exposure is the underlying cause (Rasmussen et al., 2020). Though uncommon in day-to-day civilian life, its incidence is significantly higher among those subject to high-altitude mountain environments due to cold climates and harsh weather.

Despite mild hypothermia (core body temperature <37°C) commonly going unnoticed, severe hypothermia (core body temperature <32°C) has a reported mortality rate of 21% (Danzl et al., 1987 cited in Rasmussen et al., 2020).

As highlighted in the risk assessment (Appendix A), the cold climate of Mt Elbrus presents a significant hazard to which team members will be subjected for prolonged periods. Thus, a detailed review of this hazard is justified.

Risk Assessment

Primary hypothermia is likely to occur due to cold exposure when physiological thermoregulation is impaired.

Risk factors for primary hypothermia include environment (cold, wind), clothing (wet clothing, inadequate clothing), equipment (unsuitable sleeping mat or tent), and high altitude.

Due to the lack of permanent infrastructure all team members will be subject to sustained exposure to the cold, however this risk is known, and individuals will have appropriate clothing and equipment. The risk of primary hypothermia is therefore moderate.

Risk Management

As the group of participants is small, and all have experienced similarly cold conditions without displaying adverse reactions or high sensitivity, the risk of abnormal individual susceptibility to the cold is low. Should a larger team be undertaking this climb, a pre-screening medical assessment may be required.

To mitigate and reduce the risk of hypothermia, team members will wear well-fitting, tested clothing and personal protective equipment such as goggles when appropriate. Tents and sleeping apparatus will also be rated to at least -30°C and all individuals will be trained and familiar with the equipment.

As team members will inevitably become cold during the trip, methods of re-warming and energy replenishment will be readily available; these will include high-calorie food bars, air-activated heat pads and emergency bothy shelters. Individuals will also have replacement clothing available in case their clothing becomes wet. Moreover, as paramedics and mountain guides, team members have an in-depth knowledge of hypothermia prevention and recognition, as well as methods of treatment and management.

Treatment and Management

When available, a low-reading tympanic thermometer provides the most practical method of diagnosing hypothermia (Rasmussen et al., 2020). In the absence of a thermometer, the Swiss staging system for hypothermia (Table 1) provides an effective means of diagnosing hypothermia severity based upon symptom recognition (Musi et al., 2021). The staging of hypothermia is an important method for determining appropriate treatment and management (Soar et al., 2010; Dow et al., 2019).

Stage

Symptoms

Core Temp (°C)

Treatment

HT I

Conscious,

Shivering

32–35

Warm environment

and clothing, warm

sweet drinks, and

active movement

HT II

Impaired

consciousness, no

shivering

28–32

Cardiac monitoring,

horizontal position and

immobilisation,

active external

rewarming (heat

packs and blankets) and minimally invasive

rewarming (warm IV fluids)

HT III

Unconscious, no

shivering, vital signs

present

24–28

As for HT II + airway management;

consider rewarming

with ECMO or

cardio-pulmonary

bypass

HT IV

No vital signs,

pliable chest wall

<24

HT II & III

management + ALS,

rewarming with

ECMO or

cardio-pulmonary

bypass

 

Table 1: The Swiss Staging System for Hypothermia (Strapazzon et al., 2014)

In severe cases, hypothermia can be challenging to distinguish from death, particularly in the pre-hospital environment (Musi et al., 2021). In reference to this, contemporary literature suggests that a frozen body with an incompressible chest wall is a reliable indicator that resuscitative efforts are futile (Brown et al., 2012).

In the pre-hospital environment, the goal of stage HT I patients is passive and active re-warming (Brown et al., 2012). Should primary hypothermia the suspected cause and normothermia be achieved without physiological complications, transport to hospital is not required (Musi et al., 2021; Dow et al., 2019). In patients with stage HT II to HT IV hypothermia, the priority is basic life support following a stepwise ‘airway, breathing, circulation, disability’ approach (Dow et al., 2019). Moreover, patients with stage HT II hypothermia or worse should be carefully extracted to hospital with minimal handling due to cardiac instability (Lundgren et al., 2009; Brown et al., 2012).

In the mountain environment, before treatment begins, rescue safety must first be considered to avoid further casualties ensuring. When management is possible, suitable techniques for rewarming include the following:

Protection from further heat loss by placing the patient in a warm environment, such as a bothy or sleeping bag, or replacing cold wet clothing with warm dry clothing (Musi et al., 2021). Where possible, there should be a barrier in place between the patient and the ground.

Protection from the wind reduces convection cooling. This can be achieved by donning wind-resistant clothing, taking shelter behind a natural structure or erecting an emergency bothy.

Rewarming the patient at a rate of 1 to 2°C per hour reduces the risk of arrythmia and after-drop (Giesbrecht, 2001). If the patient is shivering, they should be given warm high-carbohydrate liquids (when possible) (Musi et al., 2021).

Active external rewarming using large chemical heat pads, blizzard blankets and warm water bottles will help increase core temperature in both shivering and non-shivering patients (Hultzer et al., 2005; Lundgren et al., 2009; Lundgren et al., 2011). The most effective sites for heat pad placement are the axilla, chest and back (Hayward, 1973; Kulkarni et al., 2019; Musi et al., 2021). Body-to-body re-warming may be useful for mild hypothermia where the normothermic person is not at risk of becoming hypothermic or suffering harm.

If patients are presenting with HT II to HT IV hypothermia, evacuation from the mountain via helicopter is preferred. Where this is impossible, snowcats will be contacted. Should neither resource be available, a dynamic risk assessment will be made as to whether manual evacuation is possible and appropriate. Seeking shelter will remain a priority while evacuation is organised.

Limitations of Treatment and Management

The treatment of primary hypothermia in the mountain environment presents unique challenges, not least due to the harsh environment in which assessment and management must take place. Invasive rewarming, though effective, is inappropriate for this mountain environment. Furthermore, passive external rewarming is limited by the available weight and space in team members’ backpacks.

There is also additional concern for cardiac illness in patients requiring the long extrication from mountainside to hospital, specifically in those with hypothermia-related cardiac irritability. Ultimately, beyond pulse oximetry, there is no cardiac monitoring or defibrillator suitable for the team to carry up the mountain; thus, technological support is dependent on helicopter rescue availability. To this end, should cardiac arrest occur, resuscitation efforts in the field are likely to be futile and place the rescuer at an increased risk of harm unless helicopter medical evacuation is readily available.

Control Measures and Plan

Each team on the mountain should have a medical kit containing:

·        Blizzard blanket, including large heat pad

·        Emergency bothy (four- to six-man)

·        High-calorie foods (e.g. energy bars)

·        Stove with a wind-resistant sheath, sufficient gas and a titanium mug

High Altitude-Related Illness

Rationale

High-altitude illness covers a spectrum of altitude-related illnesses; however, it is most often referred to as acute mountain sickness (AMS), high-altitude pulmonary oedema (HAPE) and high-altitude cerebral oedema (HACE). HAI occurs due to hypoxia resulting from failed physiological adaptation to a hypobaric atmospher. If AMS occurs and individuals continue to ascend, they are at significant risk of developing HAPE and HACE, both of which have a high incidence of mortality and morbidity (Davis and Hackett, 2017).

It is widely accepted that individuals who ascend over 2000m are at risk of AMS and associated illness. Moreover, AMS affects as many as 85% of individuals ascending above 4000m (Muza et al., 2010; Kayser et al., 2012). HAPE and HACE are less common (0.1% to 0.4% incidence) and typically occur at altitudes above 4000m (Luks et al., 2014). The summit of Mount Elbrus stands at 5642m; thus, high altitude-related illness is a significant risk to which team members will be subject for a prolonged period.

Risk Assessment

During the ascent of Mt Elbrus, individuals will be ascending and sleeping above 2000m for approximately eight days. Furthermore, the team will be ascending and sleeping at increases in elevation of more than 500m daily. Consequently, there is a likely risk of several if not all team members developing some mild symptoms of AMS. Continuous monitoring of symptoms will thus be required to detect the onset of severe AMS and associated illness.

The Lake Louise Score (LLS) is an assessment tool for the diagnosis of AMS presence and severity (Table 2) (Roach et al., 2018). An LLS of 3–5 points indicates mild AMS, with moderate AMS indicated by 6–9 points and severe AMS at 10–12 points (Roach et al., 2018).

Symptoms 

Severity 

Points

Headache 

None at all 

A mild headache 

Moderate headache 

Severe headache, incapacitating 

0

1

2

3

Gastrointestinal symptoms 

Good appetite  

Poor appetite or nausea 

Moderate nausea or vomiting 

Severe nausea and vomiting, incapacitating 

0

1

2

3

Fatigue and/ or weakness 

Not tired or weak 

Mild fatigue/ weakness 

Moderate fatigue/ weakness 

Severe fatigue/ weakness, incapacitating 

0

1

2

3

Dizziness/ light-headedness 

No dizziness/ light-headedness 

Mild dizziness/ light-headedness 

Moderate dizziness/ light-headedness 

Severe dizziness/ light-headedness, incapacitating  

 

0

1

2

3

AMS clinical function score 

Overall, if you had AMS symptoms, how did they affect your activities?

 

Not at all

 

Symptoms present but did not force any change in activity or itinerary

 

My symptoms forced me to stop the ascent or go down on my own power

 

Had to be evacuated at a lower altitude

 

 

 

 

0

 

1

 

 

2

 

 

 

3

 

 

 

Table 2: Lake Louise Score (Roach et al., 2018)

Risk Management

As the risk of altitude-related illness is both high and unavoidable, all team members will undergo extensive pre-trip training on using the Lake Louise Score, as well as methods for the treatment and management of AMS, HAPE and HACE.

Radio communication will also be put in place to facilitate liaising with local rescue services and other teams on the mountain in the case of HAPE or HACE occurring.

All team members have experience in high-altitude mountaineering and therefore understand their own acclimatisation process. Having said this, a pre-trip medical screening will be completed to identify susceptible individuals. Those taking prophylactic medications will be asked to declare these during the medical screening.

First aid kits will contain emergency medication, as well as mild analgesia for symptom relief.

Monitoring and prevention will remain the primary method of risk reduction. Should individuals show symptoms of worsening AMS, ascent will be halted until symptoms resolve or descent will be initiated.

Treatment and Management

Reducing the rate of ascent or descending remains the most effective and least invasive method for managing AMS (Jin, 2017). The current Wilderness Medical Society guidelines suggest descending at least 300m but no more than 1000m (Luks et al., 2014). For the management of mild symptoms (LLS <5), ibuprofen is recommended (Kitsteiner et al., 2011). For patients with severe AMS (LLS >10) dexamethasone and acetazolamide are indicated when descent is not possible (Jin, 2017; Prince et al., 2020). To reverse hypoxemia, supplemental oxygen can be given if available (Prince et al., 2020).

Requesting portable hypobaric chambers from mountain rescue is also a viable treatment option for HAPE; however, these should be used with caution in those with HACE (Luks et al., 2014).

Should a member of the team present with HAPE or HACE, requesting medical evacuation will remain a priority in combination with descent and drug therapy where appropriate.

There is no suggestion within the literature as to the route in which dexamethasone should be administered in emergency settings. Given the challenges of intravenous cannulation in a harsh, cold environment, intramuscular injection remains a realistic route.

Limitations of Treatment and Management

Due to the subjective symptoms of AMS and the poor specificity of the LLS (Moore et al., 2020), recognition of acute altitude illness may be delayed. Furthermore, the preparation of a medication in the field environment is not without notable challenges, particularly due to the likely reduction of dexterity resulting from the cold.

An additional limitation is that bottled oxygen will not be included in medical kits due to its weight and size. The same can be said for hypobaric chambers. As a result, these items will only be available if provided by mountain rescue services. 

Control Measures and Plan

Each team on the mountain should have a medical kit containing:

·        16 x Paracetamol 500mg Tablets

·        16 x Ibuprofen 200mg Tablets

·        8 x Acetazolamide 250mg Tablets

·        4 x (4mg/ml) 1ml Dexamethasone Vial

·        2 x 2ml Syringes

·        1 x 5ml Syringe

·        1 x 10ml Syringe

·        2 x Drawing Up Needle (19G) 1.1 x 40mm Red

·        2 x Hypodermic Needle (23G) 0.6 x 25mm Blue

·        2 x IV Cannula (20G) 1.3 x 45mm

·        2 x Tegaderm Cannula Dressing

Team members will be pre-screened for drug allergies.

 

Conclusion

As a remote mountain environment, Mt Elbrus presents many innate risks that pose a hazard to those ascending it, especially via its north face. This medical plan has presented and outlined the primary risks faced by a team of four paramedics and one mountain guide attempting to summit the mountain in August.

Two exemplar risks have also been presented and discussed, along with strategies for treatment and management.

The overarching theme within this medical plan is that prior preparation and knowledge remains the most effective way of minimising the risk of harm. While this plan does not attempt to consider all eventualities, the ethos of the risk management strategies discussed can be extrapolated and extended to the wider risk management setting.

 

 


 

Appendix A – A risk assessment for ascending Mount Elbrus north route

Activity

Hazard

Harm

Risk

Control Measures

Mountain Environment

Cold

Hypothermia

 

 

 

Frostbite and frostnip

 

Non-freezing cold injury

 

Moderate

Adequate clothing

Adequate equipment

High calorie foods

Education

Adequate clothing

Education

Adequate clothing

Education

 

Rock and ice fall

Traumatic injury

Moderate

Knowledge

Weather forecasting

Route planning

 

Sun

Sunburn

 

Sunstroke

Heatstroke

 

Photokeratitis

 

High

 

Moderate

Low

 

Moderate

Sun cream

Adequate clothing

Adequate clothing

Oral fluids

Interparty monitoring

Wraparound glacier glasses rated to level 4.

Education

 

Darkness

Trips and falls

Low

Headtorch

Camp preparation

 

Avalanche

Traumatic injury

Moderate

Mountain knowledge

Weather forecasting

Route planning

 

Crevasse

Traumatic injury

Moderate

Mountain knowledge

Weather forecasting

Route planning

Rescue apparatus e.g., rope, ice screw, prusik cord and carabiner.

Camp preparation

Gas stove (cooking)

 

 

 

Foodborne illness

Waterborne illness

 

 

Carbon Monoxide poisoning

 

Burns

 

Diarrhoea and vomiting

Diarrhoea and vomiting

High

 

Moderate

 

Low

Moderate

Education

C.E. Certified cookers

Education

Equipment training

Education

Education

Water purification tables

Boil water prior to consuming

Mountaineering

Hiking

Exhaustion

 

 

Dehydration

 

Minor injury

 

High

 

 

Moderate

 

High

Education

Fitness pre-screening

High calorie food

Education

Water preparation

Well fitting equipment

Medical pre-screening

Knowledge of equipment functionality

 


 

Reference List

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Danzl, D.F., Pozos, R.S., Auerbach, P.S., Glazer, S., Goetz, W., Johnson, E., Jui, J., Lilja, P., Marx, J.A., Miller, J. and Mills Jr, W., 1987. Multicenter hypothermia survey. Annals of Emergency Medicine, 16(9), pp. 1042-1055.

Davis, C. and Hackett, P., 2017. Advances in the prevention and treatment of high altitude illness. Emergency Medicine Clinics, 35(2), pp. 241-260.

Dow, J., Giesbrecht, G.G., Danzl, D.F., Brugger, H., Sagalyn, E.B., Walpoth, B., Auerbach, P.S., McIntosh, S.E., Némethy, M., McDevitt, M. and Schoene, R.B., 2019. Wilderness Medical Society clinical practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2019 update. Wilderness & Environmental Medicine, 30(4), pp. S47-S69.

Giesbrecht, G.G., 2001. Emergency treatment of hypothermia. Emergency Medicine, 13(1), pp. 9-16.

Hayward, J.S., JS, H. and JD, E., 1973. Thermographic evaluation of relative heat loss areas of man during cold water immersion.

Health and Safety Executive, 2006. Five steps to risk assessment. Health and Safety Executive.

Hultzer, M.V., Xu, X., Marrao, C., Bristow, G., Chochinov, A. and Giesbrecht, G.G., 2005. Pre-hospital torso-warming modalities for severe hypothermia: A comparative study using a human model. Cjem, 7(6), p. 378.

Jin, J., 2017. Acute mountain sickness. Jama, 318(18), pp. 1840-1840.

Kayser, B., Dumont, L., Lysakowski, C., Combescure, C., Haller, G. and Tramer, M.R., 2012. Reappraisal of acetazolamide for the prevention of acute mountain sickness: A systematic review and meta-analysis. High Altitude Medicine & Biology, 13(2), pp. 82-92.

Kitsteiner, J.M., Whitworth, J.D. and Nashelsky, J., 2011. Preventing acute mountain sickness. American Family Physician, 84(4), pp. 398-400.

Kulkarni, K., Hildahl, E., Dutta, R., Webber, S.C., Passmore, S., McDonald, G.K. and Giesbrecht, G.G., 2019. Efficacy of head and torso rewarming using a human model for severe hypothermia. Wilderness & Environmental Medicine, 30(1), pp. 35-43.

Luks, A.M., McIntosh, S.E., Grissom, C.K., Auerbach, P.S., Rodway, G.W., Schoene, R.B., Zafren, K. and Hackett, P.H., 2014. Wilderness Medical Society practice guidelines for the prevention and treatment of acute altitude illness: 2014 update. Wilderness & Environmental Medicine, 25(4), pp. S4-S14.

Lundgren, J.P., Henriksson, O., Pretorius, T., Cahill, F., Bristow, G., Chochinov, A., Pretorius, A., Bjornstig, U. and Giesbrecht, G.G., 2009. Field torso-warming modalities: A comparative study using a human model. Prehospital Emergency Care, 13(3), pp. 371-378.

Lundgren, P., Henriksson, O., Naredi, P. and Björnstig, U., 2011. The effect of active warming in prehospital trauma care during road and air ambulance transportation- A clinical randomized trial. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 19(1), pp. 1-7.

Moore, J., MacInnis, M.J., Dallimore, J. and Wilkes, M., 2020. The Lake Louise score: A critical assessment of its specificity. High Altitude Medicine & Biology, 21(3), pp. 237-242.

Musi, M.E., Sheets, A., Zafren, K., Brugger, H., Paal, P., Hölzl, N. and Pasquier, M., 2021. Clinical staging of accidental hypothermia: The revised Swiss system: Recommendation of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Resuscitation, 162, pp. 182-187.

Muza, S.R., Beidleman, B.A. and Fulco, C.S., 2010. Altitude preexposure recommendations for inducing acclimatization. High Altitude Medicine & Biology, 11(2), pp. 87-92.

National Patient Safety Agency, 2007. Healthcare risk assessment made easy.

Prince, T.S., Thurman, J. and Huebner, K., 2020. Acute mountain sickness. StatPearls.

Rasmussen, J.M., Cogbill, T.H., Borgert, A.J., Frankki, S.M., Kallies, K.J., Roberts, J.C., Cullinane, D.C., Renier, C., Woehrle, T., Eyer, S.D. and Zein Eddine, S.B., 2020. Epidemiology, management, and outcomes of accidental hypothermia: A multicenter study of regional care. The American Surgeon, pp.2-103

Roach, R.C., Hackett, P.H., Oelz, O., Bärtsch, P., Luks, A.M., MacInnis, M.J., Baillie, J.K. and Lake Louise AMS Score Consensus Committee, 2018. The 2018 Lake Louise acute mountain sickness score. High Altitude Medicine & Biology, 19(1), pp. 4-6.

Soar, J., Perkins, G.D., Abbas, G., Alfonzo, A., Barelli, A., Bierens, J.J.L.M., Brugger, H., et al., 2010. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation, 81(10), pp. 1400-1433.

Strapazzon, G., Procter, E., Paal, P. and Brugger, H., 2014. Pre-hospital core temperature measurement in accidental and therapeutic hypothermia. High Altitude Medicine & Biology, 15(2), pp. 104-111.